Conservatory of Music Registration

Name

First NameLast Name

Please indicate all that apply:

If there are special circumstances you need to inform the Conservatory about, please use the text box below:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email address

example@example.com

Home phone number

Area CodePhone Number

Cell phone number

Area CodePhone Number

If younger than 21, enter birth date

Date

Grade in school

Employer/position or school name

Employer or school phone number

Area CodePhone Number

If the student is under 21 years of age, please complete the following:

Father/Guardian

First NameLast Name

Father/Guardian's cell phone number

Area CodePhone Number

Father/Guardian's work phone number

Area CodePhone Number

Father/Guardian's email address

example@example.com

Father/Guardian's employer and position

Mother/Guardian

First NameLast Name

Mother/Guardian's cell phone number

Area CodePhone Number

Mother/Guardian's work phone number

Area CodePhone Number

Mother/Guardian's email address

example@example.com

Mother/Guardian's employer and position

Instrument

Years of study

Teacher request (if any; for listings, see faculty listed online)

Lesson length (minutes)

Please check all days you are available for lessons

Please indicate times available on the above days and indicate your first choice

Title

Refund/Make-up/Withdrawal Policy

Refunds, credits, or make-ups cannot be given for lessons missed by the student. I understand and accept the conditions for registration/withdrawal as outlined on the Millsaps Conservatory website. Signature required below.

E-signature

Please use your mouse, trackpad, or finger on your touchscreen to sign.

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

To pay by check, please send in a check made out to Millsaps College to:

Millsaps Conservatory of Music
c/o Rachel Heard, Millsaps College
1701 North State St
Jackson, MS 39210

To pay by credit or debit card, please select the option below:

Choose one option:

Conservatory of Music Master Teacher Lessons$645.00

Length of Lesson

Conservatory of Music Student Teacher Lessons (Please confirm with the Conservatory before selecting this option!)$310.00

Length of Lesson

Conservatory of Music Musicianship Class$210.00

Conservatory of Music Small Group Ensemble$260.00

Total $0.00

Credit or Debit Card